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Request Pearl For Speaking Engagements

Postpartum Client Intake Form

Full Name: Preferred Name: Phone Number: Email Address: Baby’s Name & Age:

What type of birth did you have? (Check one):

Vaginal Cesarean VBAC Home Birth Hospital Birth

Briefly describe your birth experience:

How are you feeling emotionally on a scale of 1–10? How are you feeling physically on a scale of 1–10? What challenges are you currently facing?

How are you currently feeding your baby?

Breastfeeding Bottle Feeding Combo Formula

Would you like herbal support for milk flow? Yes No Would you like a referral to a certified lactation consultant? Yes No

Areas Where You Need Support:

Emotional Support Sleep/Fatigue Milk Flow Support Stress or Overwhelm Hormonal Balance Bonding with Baby Herbal Product Recommendations Self-Care Planning Something Else:

Please list any known allergies to herbs, essential oils, or ingredients:

Is there anything else you’d like me to know?

POP21

by Pearls of Paradisus

Inhale. Reset. Transform.

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